‘In 2 years, tech checks prevented fake claims of Rs 630 cr under Ayushman’ | Lucknow News

Lucknow: Technology-led checks, including the use of artificial intelligence and big data under Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (PMJAY), helped prevent fraudulent claims worth nearly Rs 630 crore in the past two years.“When a fraud is plugged, that money does not disappear — it is retained within the system and used to fund legitimate treatments, strengthen hospitals and expand access,” chief executive officer, National Health Authority, Sunil Kumar Barnwal said.Adding that the scale of PMJAY operations in UP naturally attracts gains from technology and savings, he said, “With the highest number of beneficiaries and claims in the country, UP is both the biggest stress test and biggest beneficiary of PMJAY’s fully digital, IT-driven architecture. From beneficiary identification and hospital admission to treatment, claim processing and payments, every step under the scheme is conducted online, with minimal manual intervention.“He said that claims were processed on a blind, first-in-first-out basis, ensuring neutrality. “Doctors adjudicating claims do not know which hospital a claim originates from, a design choice that removes discretion and bias. This is what allows PMJAY to function at scale in a state like UP without leakage,” Barnwal said.“Transparency and predictability are critical. Hospitals know payments will come on time if claims are genuine, and beneficiaries know entitlements cannot be denied arbitrarily,” he said.The same IT backbone allows UP to operate within a national health assurance framework without building parallel systems, reducing administrative costs and enabling tighter monitoring. This allows the state to focus resources on service delivery rather than system management.On how the frauds were checked, Barnwal said: “Over seven years, PMJAY generated more than 11 crore treatment records, and a substantial share was from Uttar Pradesh. This data is now central to AI-driven fraud and anomaly detection. Every claim is checked against historical patterns to flag duplicate procedures, repeat admissions, manipulated reports or reused diagnostic images.”“About 30% of system-flagged suspicious claims are eventually confirmed as irregular, a rate expected to improve as machine learning models replace rule-based checks,” he added.The state also piloted AI-based interventions, including smartphone-based cataract screening tools with reported accuracy of over 96%, enabling ASHA workers to identify patients early. AI-based screening for oral and breast cancer showed encouraging results.The impact of the scheme on households is increasingly visible. Citing the Economic Survey 2024-25, Barnwal pointed to earlier detection of cancers and a sharp fall in out-of-pocket health expenditure — from around 64% to nearly 39%.“For families in Uttar Pradesh, this protection against catastrophic health costs is transformative,” he said.Barnwal said sustaining these gains would require a stronger focus on preventive care. The transformation of health sub-centres into Ayushman Arogya Mandirs, backed by digital health records and disease surveillance, is aimed at preventing illness rather than merely paying for treatment. “If India is to become a developed nation by 2047, UP must be a healthy state,” he said.